LDA - Louisiana Dental Association
LDA - Louisiana Dental Association
LDA - Louisiana Dental Association
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LADPAC CHIPPING IN FOR DENTISTRY<br />
7th Annual Golf Tournament<br />
Registration Form<br />
Friday, October 23, 2009<br />
Pelican Point Golf Club, Gonzales, La.<br />
ENTRY FEE: $150 (includes lunch & reception)<br />
AGENDA<br />
10:30 a.m. Registration & Lunch Begins (Mulligans Available for Purchase)<br />
11:30 a.m. Shotgun Start*<br />
Tournament ends 19th Hole Reception and Tournament Awards and Prizes<br />
* Full details will be mailed to all registered golfers.<br />
Thanks to our sponsors: Robert Ellis & Associates, 3M ESPE, The Olivier Group,<br />
Campus Federal Credit Union, and Roedel Parsons. (9/2/2009)<br />
Registration : Sign up individually or as a team. Individuals will be put together to form teams.<br />
Name _______________________________________________ Telephone Number ______________________________<br />
Address ____________________________________________________________________________________________<br />
E-mail ____________________________________ Fax _____________________________________________________<br />
Golf handicap ________________________________________<br />
If you have already arranged to play with another player or players, please provide their names (and golf handicaps). Also include any of the<br />
other players on your team or any other players you would like in your foursome:<br />
___________________________________________________________________________________________<br />
___________________________________________________________________________________________<br />
Number of players ($150 each) = $<br />
Pre-pay for mulligans (limit 2 = $10) = $<br />
*Add late fee of $20 per person after Oct. 19 = $<br />
Credit card convenience fee ($15) = $<br />
Total amount of fees due to the <strong>LDA</strong> = $<br />
Payment Information<br />
Check enclosed (check box) Payable to LADPAC<br />
Visa/MasterCard Expiration Date ___________________<br />
Card Number ___________________________________<br />
Three-Digit Code, Back of Card ____________________<br />
Signature ______________________________________<br />
Register online at www.ladental.org or<br />
send completed form to:<br />
LADPAC Golf Tournament<br />
P.O. Box 261173,<br />
Baton Rouge, LA 70826-1173<br />
Phone: (225) 926-1986 or 800-388-6642<br />
Fax: (225) 926-1886 or 800-343-3842<br />
info@ladental.org or www.ladental.org<br />
Beginning August 1, 2009, there will be a $15<br />
convenience fee for each credit card transaction.